Her brother paid the ultimate price for the failings of mental health services, says the sister of Warrant Officer Patrice Vincent, a veteran soldier who was run down and killed in a Montreal-area parking lot in what officials deemed an act of terror.

But a 14-page coroner's report released in April illustrates how many times warning signs about the mental health of Martin Couture-Rouleau were ignored. He was the driver of the car that struck Patrice Vincent and a colleague who was injured on Oct. 20, 2014 in a plaza parking lot in Saint-Jean-sur-Richelieu, south of Montreal.

Couture-Rouleau was later shot and killed by police after a car chase.

"If one individual had listened, this guy would not be dead, my brother would not be dead, so that made me really, really upset," said Louise Vincent. She's only been able to read the report into her brother's death once because it upset her so much. It is the first time the family has spoken publicly about the findings of coroner Andre Dandavino.

The RCMP ruled the two soldiers were targeted, that they were run down because of the uniform they were wearing. The conclusion was this was an act of terror by a radicalized lone wolf inspired by ISIS. After he hit the two soldiers, Couture-Rouleau called 911 with a message for the government to stop its war on ISIS.

But the coroner's report makes it clear that Couture-Rouleau's father made repeated cries for help to mental health agencies and police. His son had a family history of mental health problems and had lost his job and broken up with his girlfriend.

Couture-Rouleau, 24, was smoking 25 joints of marijuana a day. He had converted to Islam and was embracing conspiracy theories about the 9/11 attacks. He was lauding al Qaeda in a blog, watching violent videos and communicating with Muslim extremists online.

But the coroner's report concludes that staff at an outpatient psychiatric clinic that Couture-Rouleau voluntarily contacted in August 2013, decided he did not need to see a psychiatrist because he refused to believe he was sick.

In his report, the coroner called that decision "questionable" because the young man was showing signs of delusion and lack of touch with reality.

"At that point I was very angry because I was like, this should have never happened, what kind of society are we?" said Vincent. She says Couture-Rouleau's father showed great courage. He even returned to the clinic where his son was evaluated, but was unsuccessful in convincing staff to intervene.

"And all the father's efforts that he did, all the people he reached out to and there was no help."

A coroner does not adjudicate blame in an incident, instead making recommendations aimed at preventing similar deaths. Dandavino recommended training for front-line mental health staff to recognize and evaluate people who present with signs of radicalization and psychiatric symptoms. Those people should be evaluated by a psychiatrist, says the coroner.

Vincent says she hopes the recommendations will be taken seriously.

"If there could be something in place that could be sound and secure and solid, at least that would put some meaning into his death."

With a report from CTV News Montreal bureau correspondent Genevieve Beauchemin